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SYMPOSIUM: CRITICAL POINT OF CARE BIOMARKERS IN EMERGENCY CARE
Year : 2014  |  Volume : 4  |  Issue : 3  |  Page : 216-222

Point of care blood gases with electrolytes and lactates in adult emergencies


1 Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
2 Department of General Medicine, Government Medical College and Hospital, Chandigarh, India

Date of Web Publication23-Sep-2014

Correspondence Address:
Dheeraj Kapoor
1207, Sector 32 B, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5151.141411

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   Abstract 

Point-of-care testing (POCT) is one of the formidable concept introduce in the field of critical care settings to deliver decentralized, patient-centric health care to the patients. Rapid provision of blood measurements, particularly blood gases and electrolytes, may translate into improved clinical outcomes. Studies shows that POCT carries advantages of providing reduced therapeutic turnaround time (TTAT), shorter door-to-clinical-decision time, rapid data availability, reduced preanalytic and postanalytic testing errors, self-contained user-friendly instruments, small sample volume requirements, and frequent serial whole-blood testing. However, still there is a noticeable debate that exists among the laboratorians, clinicians, and administrators over concerns regarding analyzer inaccuracy, imprecision and performance (interfering substances), poorly trained non-laboratorians, high cost of tests, operator-dependent quality of testing, and difficulty in integrating test results with hospital information system (HIS). On search of literature using Medline/Pubmed and Embase using the key phrases "ppoint-of-care test," "central laboratory testing," "electrolytes," "blood gas analysis," "lactate," "emergency department," "intensive care unit," we found that POCT of blood gases and selected electrolytes may not entirely replace centralized laboratory testing but may transfigure the clinical practice paradigm of emergency and critical care physicians. We infer that further comprehensive, meaningful and rigorous evaluations are required to determine outcomes which are more quantifiable, closely related to testing events and are associated with effective cost benefits.

Keywords: Blood gas analysis, central laboratory testing, emergency department, electrolytes, intensive care unit, lactate, point-of-care test, therapeutic turnaround time


How to cite this article:
Kapoor D, Srivastava M, Singh P. Point of care blood gases with electrolytes and lactates in adult emergencies. Int J Crit Illn Inj Sci 2014;4:216-22

How to cite this URL:
Kapoor D, Srivastava M, Singh P. Point of care blood gases with electrolytes and lactates in adult emergencies. Int J Crit Illn Inj Sci [serial online] 2014 [cited 2019 Oct 21];4:216-22. Available from: http://www.ijciis.org/text.asp?2014/4/3/216/141411


   Introduction Top


The most imperative aspect of patients in emergency and critical care settings is their dynamic physiological status with rapid deterioration that may require early diagnosis and clinical decisions to be made for better patient outcome. These settings include intensive care units (ICU) including burn, trauma, chest pain and stroke units, operating rooms (OR), emergency department (ED), pre-hospital transport systems (ambulance). Along with various "vital signs" such as, blood pressure, heart rate and rhythm, temperature, and respiratory rate, some biochemical markers reflect these rapid changes resulting in patient's unstable physiology. [1] Most frequently, electrolytes and acid-base disorders result in difficulty in weaning patients off the ventilator, prolonged admission periods, preventable cardiac arrhythmias, and cardiac arrest. [2] These situations require prompt lab results, most of which are done serially, ideally a point of care test (POCT), to meet the urgency of clinical decision and avoid subsequent damage to vital organs and systems. [1],[2] POCT improves patient's outcome through real-time treatment of the physiological deterioration. [1] The prime advantage of POCT is reduced therapeutic turnaround time (TTAT) and shorter door-to-clinical-decision time. [3],[4] Other advantages are rapid data availability, reduced preanalytic and postanalytic testing errors, self-contained and user-friendly instruments, small sample volume requirements, and frequent serial whole-blood testing. [1],[3],[5] Major concerns are regarding analyzer inaccuracy, imprecision and performance (interfering substances), poorly trained non-laboratorians, high cost of tests, operator-dependent quality of testing, and difficulty in integrating test results with hospital information system (HIS). [3] This review is based on literature search using Medline/Pubmed and Embase using the key phrases "point-of-care test," "central laboratory testing," "electrolytes," "blood gas analysis," "lactate," "emergency department," "intensive care unit" within a period between 1990 and 2013. The selection is focused on literature pertaining to the issues regarding the practicability of POCT of blood gases, electrolytes, lactates, and various POCT devices associated in existing critical care settings. Only articles in English were chosen.


   Arterial blood gases Top


As reported by the National Committee for Clinical Laboratory Standards, arterial blood gas (ABG) analysis has a prospective influence on patient care than any other laboratory determinants. [6] Tissue oxygenation, ventilation, and acid-base status are the most important factors in the management of critically ill patients admitted in ED and ICU. The sudden changes in these parameters may result in life-threatening situations; hence rapid results are frequently required for effective management. Non-invasive methods such as pulse oximetry and capnometry may not equate accurate measurements of oxygenation and ventilation, due to abnormal physiological conditions in emergency situations. [7]

POCT is of enormous help in pre-hospital emergency settings and are employed for past many years with immense success. [7],[8] It is mainly indicated in cardiopulmonary resuscitation (CPR), hypoxemia, suspected acidosis, cardiogenic shock, cardiac arrhythmias, and for control of mechanical ventilation. [7],[8] The management strategies in these life-threatening conditions immensely rely on rapid blood gas analysis. Pulse oximetry is commonly employed for detecting hypoxia, though requires an adequate pulse wave to display accurate readings. [7] Most of the patients in pre-hospital settings are in severe shock in which pulse oximetry is of not much help. [7] Similarly, capnometry may underestimate arterial pCO2 in severe cardiovascular insufficiency or during CPR. [9],[10] POCT devices with rapid blood gas analysis are essentially required in these situations to optimize oxygenation and ventilation. [7],[8],[9],[10]

Fermann et al., [11] reviewed nearly 100 articles which distinctly assert that POC technology is effective and reliable in ED settings and provide improved patient care. There is fair evidence that POC blood gas testing leads to reduced TTAT when compared with central laboratory testing (CLT), resulting in improved clinical outcomes. [12] A study conducted by Barquist et al., [13] on 116 nonintubated adult blunt-trauma patients in ER, advocated that ABG analysis should be instituted in all blunt-trauma patients as it may be of huge help in triage of those patients who require early mechanical ventilation. Studies have found that rapid result obtained by POC blood gas testing leads to faster decision time when compared to CLT and subsequent change in appropriate management strategies, hence reducing the overall morbidity. [14],[15],[16]

POC blood gas testing also plays an instrumental role in ICU settings. Rapid and frequent arterial blood gas monitoring is particularly required for assessment of pulmonary functions with subsequent adjustments in ventilator parameters and during the initiation of early goal-directed therapy (EGDT) in patients with sepsis. [12],[17] There is fair evidence in support of POC blood gas analysis for providing better clinical outcomes of patient admitted in ICU by reducing TTAT, lesser errors, and reduced blood loss. [2],[12],[14],[17],[18],[19] However, there are certain shortcomings in POC blood gas analysis when compared with CLT. An earlier study by Winkelman et al., [20] observed that the medical cost was far less while using CLT and TTAT of POC blood gas analysis was nearly equalled to CLT. Kilgore et al., [21] evaluated POC blood gas testing with satellite and central blood gas laboratory for staff satisfaction and found that although the TTAT of POCT devices and satellite blood gas laboratory is faster than CLT, the staff satisfaction was highest with satellite blood gas laboratory. A prudent approach to attain large possible benefits from POCT devices in critical care settings is a major challenge to POCT. It should be rather considered as an adjunct instead of replacement of CLT to simplify the laboratory analysis process for the clinicians. A close collaborative association with CLT and establishment of POCT programme is an utmost requisite to attain a more robust POCT implementation and to achieve a rapid, accurate, and cost-effective result in critical care settings. [22] More studies are required to evaluate the effects of POC blood gases analysis in critically ill patients.


   Electrolytes Top


Sodium, Potassium, Chloride

Electrolyte abnormalities can trigger life-threatening events in emergencies. Hence, rapid and precise assessment of electrolyte abnormalities plays a decisive role for instituting precise therapeutic management. Various studies have outlined that POCT considerably reduce TTAT when used for measurement of electrolytes in the ED and adult ICU when compared to the central laboratory testing and may expedite the decisions on patient management and subsequent outcomes. [2],[4],[19],[22],[23],[24],[25],[26] However, contradictory results were observed while analysing the exact values of major electrolytes by either POCT or CLT methods. [23],[25],[27] The exigency of the assessment is often punctuated by deficiency of adequate human couriers or rapid transit systems (RTS) for transporting samples to central laboratories, leading to considerable delay in results and consequent long TTAT. [23],[28]

The results observed from the earlier studies showed a significant difference between the mean values of sodium and potassium obtained by POC blood gas analyzer and CLT. [23],[25],[27] This could be probably attributed to the characteristics of different devices, variations in the calibrator used in device, type of sample used (whole blood vs. serum), dilution agent used, and the effect of transportation on samples. [23],[24],[25] Chako et al., [23] compare whole blood electrolyte estimation with POCT device versus serum electrolyte estimation with CLT. They observed that the difference in values were large, particularly of potassium with values below 3 mmol/L. However, the difference for potassium values >3 mmol/L and sodium values were observed to be uniform and in good concordance. [23] They quantified the magnitude of difference between two aforesaid methods of estimations and suggested the "correction factor" that could be applied to the POCT values to attain accurate results. [23] The characteristics of electrodes used for analysis may also influence the difference between the two methods of estimations. [23] Most of the POCT analyzer has direct ion-selective electrodes, which measure the activity of ions in plasma. In contrast, the CLT analyzer has indirect ion-selective electrodes and measures the activity of ions in pre-diluted sample and is affected by dissolved solids such as proteins, hence influencing the values obtained by various electrodes. [23],[29] Chhapola et al., [24] compared the reliability of POC sodium and potassium estimation in pediatric ICU population. They found that POC blood gas analyzer underestimates the sodium and potassium values. [24] They infer that it may be due to the addition of liquid sodium heparin added to the sample which increases the volume of the sample and dilutes its plasma portion, resulting in lower values of measured electrolytes. Further, the high volume of heparin binds with electrolytes and underestimates the values of electrolytes. [30] They advocated the formulation of standardize sampling protocol, formal training of the manpower, and formation of correction equation, before introducing POCT devices in any institute to offset the sampling errors. [24] They stressed for use of dried balanced heparin syringes instead of conventional syringes with liquid heparin, to attenuate the errors further due to dilution effects. [24] Clinicians frequently calculate anion gap (AG) and the strong ion difference (SID; quantitative measure of unmeasured anions) from electrolytes value, which assist them in outlining the acid-base status and guide them for clinical decision making. A study by Morimatsu et al., [25] observed that the differences between the electrolyte values (sodium and chloride) obtained by POC analyzer and central laboratory automated biochemical analyzer, significantly affects the conventional AG and SID values with marked variations. These variations may lead to significant misinterpretations and misdiagnosis and could confound the clinical management strategies. Currently, there are limited studies to evaluate the efficacy of POC electrolyte analyzer and certainly needs more prospective controlled trials for its evaluation in critically ill patients. [12]

Ionized calcium

Early measurement of ionized calcium is an integral element for delineating the efficient and swift management of critically ill patients in the ED, ICU, and OR. [12] Zivin et al., [31] showed that hypocalcemia was associated with higher mortality and correlates with severity of illness. Earlier studies have revealed the use of 0.70 mmol/L as low-limit threshold for ionized calcium. [32] In ED and ICU, the instant values are primarily significant in patients suffering from cardiac arrest. In these patients ischemia and subsequent loss of Adenosine triphosphate (ATP) leads to the collapse of transmembrane calcium gradient in the myocardium with resultant marked elevations of cytosolic calcium, which eventually leads to significant disturbances in myocardium functions. [33],[34] In ICU settings, prompt values of ionized calcium are particularly needed in patients with sepsis, hypocalcemic crisis, hyperkalemic dysrhythmia, intractable hypotension, heart failure, shock burns and those requiring multiple blood transfusions. [31],[33],[35],[36] In OR, the repeated and prompt values of ionized calcium is underlined for patients undergoing cardiopulmonary bypass and liver transplant surgeries. [12] The POCT of ionized calcium may play a pivotal role with fair evidence for critical management of aforementioned patients in ICU and ED with rapid TAT and reduces blood utilization. [12] However the evidence in support of surgical patient is minimal and need further prospective studies. [12]

Magnesium

A substantial number of experimental, epidemiological, and clinical studies demonstrate the crucial role of magnesium in the cardiovascular pathobiology. [37],[38],[39] It is a major regulating factor in cardiac conduction and contraction, vascular tone and to cardiac rhythm, output and blood pressure. It is also a cofactor in numerous enzymatic reactions involved in energy exchange and elimination of oxygen free radicals. [38],[40],[41] POCT of magnesium with rapid TAT may be a decisive asset for critical carers for guiding early magnesium therapy for the patients with cardiac dyarrythmias, reperfusion injury, or significant inflammatory response. [40],[42] In addition, it may be of prodigious aid in ED for initiating early magnesium therapy in plethora of acute clinical situations such as intractable asthma, pre-eclampsia/eclampsia, cerebrovascular accident (CVA), seizures, acute coronary syndrome (ACS), diuretic therapy, adverse drug reactions (nitrates, ACE-inhibitors), and coagulation problems. [12],[38],[40],[43] However, there is still insufficient evidence that POCT of magnesium measurements may generate improved clinical outcomes in critically ill patients and hence needs further studies for comprehensive evaluation. [12]

Lactates

In critically ill patients, most frequently encountered pathology is severe sepsis, as a primary or secondary cause of physiological deterioration. Septicaemia triggers systemic inflammatory responses and a cascade of circulatory abnormalities comprising peripheral vasodilatation, intravascular volume depletion, myocardial depression, increased metabolism with increased oxygen demand, and decreased tissue perfusion, resulting in global tissue hypoxia, shock and multi-organ failure. [44],[45] Lactate concentrations increase with decreasing tissue perfusion due to anerobic cellular respiration. [45] Lactate levels therefore, indicate illness severity whose progression occurs during the critical "golden hours". [44],[46] An early detection and treatment guided by lactate levels during this golden period result in maximum benefit in terms of better outcome. [12],[44] Other situations where hyperlactatemia can occur are low cardiac output states, acute liver failure, uncontrolled diabetes mellitus, advanced malignancy, acquired immunodeficiency syndrome (AIDS), seizures, poisoning, and with some drug therapies. [46]

Various studies have shown prognostic value of serum lactate levels in terms of mortality and ICU or hospital stay. Moore et al., [45] found that lactate levels of patients with severe sepsis on admission, determined by handheld portable analyzer, were able to predict mortality with 81% accuracy. Patients with lactate concentration ≥4.0 mmol/L had a sevenfold increased risk of mortality than those with <4.0 mmol/L (sensitivity 88.3%). Also, none of the patients having lactate levels <2.6 mmol/L at admission died in hospital (100% sensitive marker). [45] Soliman and Vincent, [46] have found that hyperlactatemia (serum lactate concentration ≥2 mEq/l) on admission to ICU was associated with higher mortality (23 vs. 9%) and increased organ dysfunction leading to increased length of ICU stay and Sequential Organ Failure Assessment (SOFA) scores (≥5). Also, non-survivors had higher concentrations persisting up to 24-48 hours. [46] Recently a systematic review by Brothwick et al., [47] has suggested that whole blood, plasma, or serum lactate levels lack specific prognostic value. Though, there may be a role of monitoring serum lactate in ICU, if the treatment is aimed at its normalization. [47] In a retrospective study by Martin et al., [48] it was seen that patients with metabolic acidosis had higher mortality (11.4 vs. 7.3%), though pH and base-excess were not individually associated with it. They came up with the concept of "relative hyperlactemia", where patients with elevated lactate levels but in usual acceptable range, were associated with increased mortality and suggested that monitoring the course of this metabolic parameter might be a reasonable approach for ICU patients. [48] Rivers et al., [44] chose more definitive resuscitation end-points, confirming a balance between systemic oxygen delivery and demand, which included mixed venous oxygen saturation, pH, base deficit, and arterial lactate concentration. Study revealed that early goal-directed therapy resulted in significantly lower Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, Simplified Acute Physiology Score II (SAPS II), and Multiple Organ Dysfunction Score (MODS), with significantly lower in-hospital mortality rates and shorter hospital stay. [44] Rossi et al., [49] used a combination of goal-directed therapy amended by serially measured serum lactate levels by point-of-care testing, in postoperative period of patients undergoing congenital heart surgery and showed markedly decreased mortality especially in patients with higher risk. Jansen et al., [50] used serial lactate monitoring with resuscitation aimed to decrease lactate levels, in ICU patients admitted with hyperlactatemia (≥3.0 mEq/L), for initial 8 hours. It was observed that lactate group received more fluids and vasodilators, had significantly decreased risk of hospital death (predefined risk factors adjusted), reduced organ failure (SOFA score), and were weaned quicker from mechanical ventilation and inotropic support. [50] With these recent evidences, monitoring of serial lactate levels seems to be a prudent approach.

Boldt et al., [51] showed that lactate concentrations measured by a battery-powered handheld lactate analyzer (AccusportA) or a bench-top blood gas analyzer (Chiron 865 series), were in excellent agreement with central laboratory values. Use of these POCT devices, save significant amount of time (central lab, 45-168 min vs. POC system, 1-10 min), especially when early detection and serial measurements are required. [51] Also, these POCT devices facilitate serial measurements at significantly lower cost, with faster turn-around-time and reduced potential for errors. [51]


   Do Poct Devices Ready To Replace The Central Laboratory Equipments ? Top


Having known the importance of point-of-care measurement of blood gases, electrolytes and lactate in critical care and emergency department, we further need to evaluate whether these measurements are accurate and/or reliable for practical application. Literature has been reviewed to determine whether POCT devices can actually work sufficiently as a substitute for central or satellite laboratories.

POCT devices are available as bench-top, portable, and handheld formats. Some of the marketed POCT devices available are-IRMA arterial blood gas analysis system (DIAMETRICS, ChemoMedica-Austria, Vienna, Austria), GEM Premier 3000/4000 (Instrumentation Laboratory, Lexington, MA, USA), i-STAT point-of-care system (Abbott point-of-care, East Windsor, NJ, USA), Stat Profile Critical Care Xpress analyzer (STP CCX, Nova Biomedical, Waltham, MA, USA), Rapidpoint 405 (RP405; Siemens Healthcare, Sudbury, UK), ABL 700/725/825/90-FLEX (Radiometer Medical A/S, Bronshoj, Denmark), Cobas b 123 (Roche Diagnostics, Graz, Austria), Nova Lactate plus (Nova Biomedical, Waltham, MA, USA), Rapid lab 865 (Siemens, Germany). Although, their portability and quick results provides them an edge over conventional central laboratory analyzers, there are appreciable concerns regarding their performance, maintenance, quality control and ease of operation by non-laboratory staff such as nurses and physicians. Analytic performance of a device is assessed through imprecision and inaccuracy of test results in comparison to some reference or standard instrument. Imprecision (within-run and between-run) is inversely related to coefficient of variation (CV) from the test result data of a given device while inaccuracy is estimated form coefficient of correlation (r) from the set of data from the two devices- analyzer (POCT) and comparator (Central Laboratory). [52] There have been trials conducted for head-to-head comparison between POCT devices and conventional central laboratory equipment for analytic performance with analytes (blood gas parameters, electrolytes, and lactate) and practicability (ease of operation and user interface, quality control, and maintenance, etc.) Beneteau-Burnat and Pernet et al., [52] showed that GEM Premier 4000 device had CV lower than the imprecision goals and high coefficient of correlation (r = 0.92) when compared to central laboratory equipments-ABL 725 (Radiometer) and OMNI S (Roche Diagnostics, Basel, Switzerland). Also, the instrument was accepted with ease by both technical and non-technical staff. Indeed, training of non-technical staff required only 30 minutes of formal training. [52] Karon and Scott et al., [53] measured lactate values in critically ill adult and pediatric patients and compared three whole blood lactate methods (Radiometer ABL 725, i-STAT, and Nova Lactate Plus) with two plasma-based central laboratory methods (Roche Integra and Vitros). There was good correlation between two methods in clinically relevant lactate ranges, however, at high lactate values (>54.1 mg/dl, [6 mmol/L]). Radiometer and i-STAT reported lower while Nova analyzer reported higher lactate levels than laboratory. [53] Vanavanan and Chittamma, [42] assessed Stat Profile Critical Care Xpress analyzer (STP CCX) for measuring various analytes (pH, blood gases, Hct, tHb, sodium, potassium, chloride, glucose, lactate, BUN, ionized calcium, and ionized magnesium). They found high to very high correlation when compared to laboratory values (coefficient of variation ranging from 0.1% to 4.3%, and the recovery was 100% ±3%) although there was significant mean difference and large bias for values of pCO2, pO2, and Cl . [42] Recently, a study by Leino and Kurvinen, [54] compared three stat platforms (i-STAT, Radiometer ABL 825, RapidLab 865) with two core laboratory platforms (Roche Modular P800 and Sysmex XE-2100) to assess the interchangeability of results for electrolytes, glucose, lactate, and hemoglobin. Measurement values of potassium, lactate, glucose, and hemoglobin had highly correlated with laboratory (r-value 0.89-1.00), while those of pH, pCO2, pO2, and calcium showed good correlation with biases acceptable in clinically relevant ranges (r-value 0.96-1.00). [54] Significant mean differences and bias were found for sodium values. [54] Another study conducted by Koninck and Decker et al., [55] evaluated four cartridge-type POCT blood gas analyzers (RP405, GEM 4000, ABL90 FLEX, and Cobas b 123) and demonstrated that RP405 and ABL90 FLEX performed well, irrespective of the level of control material (for pH, ionized calcium, potassium, lactate, glucose, and tHb) while GEM Premier 4000 had worst precision, however, all instruments were appreciated as user-friendly. [55] The aforementioned studies clearly states that POCT devices may provide comparable results with reference to central laboratory equipments and meet analytic quality specifications for majority of test parameters. Deviations or bias in results for any specific analyte may occur from one device to another however they tend to occur at extremes of analytic range which may not always have clinical and physiologic implications. Ease-of-operation and low maintenance, tilt the balance in favor of POCT devices over central laboratory investigations.


   Conclusion Top


In emergency and critical care settings the blood-tests menu which specifically includes the provision of selected electrolytes, lactates, and blood gases at the bedside can remarkably improve the clinical decision making and patient outcomes. Emergency and critical care physicians should synergistically work with laboratorians for continual appraisal of emerging technological advancement such as POCT solutions, in order to obtain rapid test results and eventual clinical decisions. This leads to operational cost cutting and improve staff efficiency, which further may upgrade the clinical outcomes. However, debates still exist between laboratorians, clinicians, and administrators pertaining to the cost and execution of emerging POCT technology when compared with conventional laboratory testing. With existing literature we infer that POCT of blood gases and selected electrolytes may not entirely replace centralized laboratory testing but may transfigure the clinical practice paradigm of emergency and critical care physicians. We believe that further comprehensive, meaningful, and rigorous evaluations are required to determine outcomes which are more quantifiable, closely related to testing events and are associated with effective cost benefits.

 
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